Friday, May 28, 2010

The current political debate in Massachusetts about rising health care costs and insurance company premiums is a striking case of denial. The most thorough evaluation of the underlying causes of inflation was presented by the state's Attorney General this past winter. She found that the long-standing and current disparities in pricing in the Massachusetts market contribute mightily to the growth in health care costs and insurance premiums in the state. As noted in this Boston Globe story, her staff put in thousands of hours studying the issue:

The report, the result of legislation that directed Coakley to investigate why medical costs are rising so rapidly, is based on tens of thousands of contracts and other documents subpoenaed from insurers and providers and depositions from more than 30 key health care executives.

In light of the AG's conclusions, you would think that policymakers would be spending their time to design measures to reduce the disparities in reimbursement rates. But, as noted below, the policies being ordered by the Administration and the actions being taken by the insurers tend to do just the opposite.

In this kind of situation, where does one find the leadership to deal with these problems? The insurers have been willing or forced participants in creating the current situation. Can we expect them to change their stripes and take firm action against dominant providers?

During the hearings on these matters held by the state's Division of Health Care Finance, the witness from Blue Cross Blue Shield said that even his company, the largest in the state, did not have the market power to offset that of the dominant provider group and individual hospitals with special geographical advantages. That such was the case with smaller insurers was demonstrated years ago when Partners Health Care forced Tufts Health Plan to bend, but whether the same would apply to the dominant insurer remains an untested proposition.

We certainly cannot expect those providers who have benefited from higher rates to voluntarily accept cuts that would take them to the statewide average in a timely fashion. For one thing, their cost structures have been built on the expectation of greater revenues.

I believe the leadership has to come from the business community, those firms whose payments of insurance premiums -- or whose self-insurance arrangements -- validate the current reimbursement patterns. Their goal has to be to support market shifts to higher value providers. The business community needs to demand that the state government use its existing authority to expand upon the AG's work and present a clear picture of the current situation.

The "moral outrage" that would support value-driven market shifts will not come until the state chooses to publish actual rates paid to hospitals for commonly used services, and until the state also publishes clinical outcome data in a clear and up-to-date manner. Once these numbers are seen, employers and individual subscribers will discover that they are paying way too much to certain providers for services than can be delivered just as well by lower priced providers.

Once this information is freely available, the market will respond, with employers demanding and offering tiered products that more people would find acceptable. Consumers would then turn to providers who offer greater value, just like they do in other service industries.

For reasons I do not understand, neither the Administration nor the insurers have endorsed this kind of transparency, much less implemented it. Instead of being honest brokers in a transition to a more value-based health care system, they remain in steadfast denial of the AG's well researched and thoughtful conclusions.

Over the coming weeks, we should measure parties' commitment to change by the degree to which they advocate and adopt the kind of transparency that exists in virtually every other segment of the economy. If they do not, we will have to assume that they are motivated instead by self-protection of their owned perceived political and economic interests.

Thursday, May 27, 2010

I understand the Senate confirmation process in Washington, DC, and how the appointment of individuals gets hung up for a variety of political reasons. I don't particularly like it, but I understand it.

But I don't understand how with regard to the appointment of Don Berwick as head of CMS, the Medicare agency, this can be the case, as reported recently in the Boston Globe:

Senator Scott Brown, a Massachusetts Republican, has not decided how he will vote, a spokesman said.

That Don Berwick is an internationally renowned expert in health care delivery is not in doubt. That he is an honest, hard-working, and thoughtful person is also clear to the thousands of people in the health care professions with whom he has worked. That his primary focus has always been on reducing harm and medical errors is likewise the case. He is also interested in reducing costs in the health care delivery system when such costs represent waste and inefficiency.

Scott, the issue here is not whether the recently passed health care bill was right or wrong for the country. I respect your opinion on that matter. But that vote has been taken.

The issue here is whether you want someone who knows enough about the delivery of health care, whose passion is making that safer for patients, to be in charge of the agency that potentially has the largest single impact on that goal.

As a State Senator, you were always incredibly supportive of us at BID~Needham Hospital in our desire to offer safe and efficient health care to your constituents. Please know that Don Berwick and the people working with him at the Institute for Healthcare Improvement taught us how to do that.

Please don't stand by as his appointment is delayed. Please talk to your colleagues and help Dr. Berwick be confirmed as head of CMS.

Wednesday, May 26, 2010

As you have seen in examplesbelow, BIDMC is engaged in adopting the Lean philosophy to enhance our effectiveness in taking care of patients. An underlying premise of Lean is a respectful work environment for our staff, valuing each person and empowering him/her to call out problems and participate in improving things.

This approach raises a question, though. What leadership characteristics are appropriate to support the approach that characterizes a Lean company?

Yesterday, Gene Lindsey (CEO of Atrius Health) and I shared a podium in a session for human resource professionals, and he drew on the work of Robert Greenleaf to offer his view. Greenleaf set forth the concept of "servant leadership." Here's an excerpt:

"The servant-leader is servant first… It begins with the natural feeling that one wants to serve, to serve first. Then conscious choice brings one to aspire to lead. That person is sharply different from one who is leader first... The difference manifests itself in the care taken by the servant-first to make sure that other people’s highest priority needs are being served. The best test, and difficult to administer, is: Do those served grow as persons? Do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servants?

Coincidentally, this kind of approach was recently reflected to a group of our senior leaders by Mike Hoseus, Executive Director of the Center for Quality People and Organizations. (Mike is the co-author of Toyota Culture.) He presented an inverted organizational pyramid. Instead of the usual pyramid showing the CEO atop, this one shows the CEO at the bottom, followed by the vice presidents, senior managers, and group leaders. At the very top are the suppliers, team members, and customers. Nonetheless, without the energy and commitment of the CEO to the Lean endeavor, it will fail.

An audience participant at yesterday's HR session skeptically raised the question of the sustainability of the Lean approach in a corporate setting. Citing previous management fads like re-engineering, six sigma, and the like, what assurance is there that the lessons of Lean will take hold and persist beyond the term of a given CEO? We answered that there is no concrete assurance. Each CEO employs his or her own management philosophy.

But I have a feeling that, properly implemented, Lean is remarkably subversive in this respect: Once you teach staff to be "wiser, freer, more autonomous," a successor CEO is going to find it pretty hard to undo those characteristics. Indeed, a Board of Directors would find itself compelled to search out candidates who have a similar underlying philosophy.

This is not to say that there is an inevitable persistence to the use of Lean in an organization. Like physical systems in which entropy takes over, consistently applied energy is necessary to maintain the process improvement system that we call Lean.

Monday, May 24, 2010

Many months ago here and often in private with my hospital colleagues, I have advocated for a formal rate-setting process for hospital reimbursement rates. (To the best of my knowledge, only Maryland currently has such a system.)

The reaction from the industry has been uniformly negative. "How can we let faceless bureaucrats in the state government decide on the fees that hospitals could charge for care?"

My answer is that for years we have let unaccountable insurance companies do the same thing. This has led to the current disparities in pricing in the Massachusetts market, a phenomenon that the Attorney General found to be partially responsible for the growth in health care costs and insurance premiums in the state.

Now, the state insurance commissioner has expanded the power of insurance companies to do more of the same. By enforcing arbitrary rate limits on certain policies, the commissioner has, in essence, directed the insurance companies to take money out of the hands of the hospitals and doctors. And, sure enough, it is happening, as noted in this Boston Globestory.

As I have mentioned, this approach serves mainly to increase the current disparities in payments.

So, on the one hand, we hospitals oppose rate-setting. On the other hand, we let it happen to us. But instead of having an administrative state agency whose hearings would be open to public scrutiny and whose determinations would be subject to judicial review, we now have insurance company personnel making these decisions in private sessions. Their rate-setting decisions are not public and are made without accountability.

Sunday, May 23, 2010

The Southcoast Hospitals Group in southeastern Massachusetts recently announced an affiliation with the physicians from the M.D. Anderson Cancer Center in Texas. An excerpt:

The M. D. Anderson Physicians Network affiliation is offered selectively to qualified community hospitals and their medical staffs in the U.S. only after a rigorous and extensive evaluation process based on evidence-based treatment guidelines and quality management. This affiliation will enable patients to be treated at Southcoast with the assurance of best national practices in patient care. Because of this relationship the expert staff and physicians of Southcoast Centers for Cancer Care will be able to closely collaborate with M. D. Anderson and bring more than 100 evidence-based treatment regimens for almost every type and phase of cancer to the community.

This, if I may say so, is big news and a coup for the folks at Southcoast. No one can doubt the expertise now being brought to New England by the M.D. Anderson doctors. Another quote from the press release:

By building a strong community program with access to the nation's top-performing cancer program, we are assuring our community advanced care and clinical outcomes. We want our patients to rest assured their treatment plans are being measured against proven benchmarks with great outcomes and quality oversight.

In a previous blog post, I discussed the difference between zero-sum competition in the health care marketplace and competition that adds value for the community. Here, Southcoast has traded on the perspective and expertise offered by an out-of-region center to add benefit to its patients.

Let's note that the relationship requires no purchase or transfer of assets, nor transfer of control that undermines the local ownership or authority of the independent Southcoast system. While there are certainly business terms that require compensatory payment for services rendered, the context is one of a respectful and collaborative clinical relationship.

Anna Jaques -- BIDMC

Last week, Anna Jaques hospital in Newburyport announced a clinical affiliation with BIDMC. Here's an excerpt from Katie Farrell Lovett's story in the Daily News:

Under the affiliation, Anna Jaques will remain an independent, nonprofit hospital, but any "holes in the services" at the hospital will be filled through the new relationship with Beth Israel Deaconess, and services will be strengthened, beginning with specialty cardiovascular care and high-risk pregnancy care.

The origin of the relationship was a strategic review by Ana Jaques in which the community expressed a desire for the local hospital to supplement its service offerings by creating a partnership with an academic center.

CEO Delia O'Connor . . . stressed that the affiliation will not change the role of the Newburyport-based community hospital.

"Anna Jaques is staying Anna Jaques," she said. "This is not a business merger or change in ownership. We're not being taken over by a big Boston hospital."

As I mentioned below, our business plan is to look for community-based partners -- hospitals and physician practices -- for whom we can respectfully help to deliver coordinated care. Ownership, takeover, and reduction in local control is not our goal.

We do not foreclose the possibility that a community-based organization might seek corporate integration in addition to a service-based collaboration. But, even then, we would want an assurance, based on actual experience, that a corporate restructuring is based on a successful record of clinical integration and respectful relationships between our physicians and other staff.

Saturday, May 22, 2010

Monique Doyle Spencer files this report from Samuel on his first trip under the auspices of the Bucket Brigade, a small charity helping the village of Yirol in the Sudan. (Please donate here.)

Our first bulletin!

Samuel’s first Bucket Brigade trip ran into every possible travel obstacle, but he has hit the ground running in South Sudan. Part of his assignment is to build community for what we are doing, and he has already met with the governor, the bishop of the missions, the commissioner and the elders. He has recruited his old friend in Yirol, Abraham, to help him and they are working hard to meet with the villagers and see what the highest priorities are. As you’ll see, because we are small we can be flexible enough to respond to urgency, too.

Samuel: News from Yirol # 1

Everywhere I go, I hear the same response: “This is a beautiful idea.” The people here are suffering badly and they are so happy to find out that someone cares about them. They know the donors and founders are halfway around the world but if any of you wants to visit here, you will be treated like royalty. The people are just so happy. It’s a profound happiness, to feel that someone is holding out a hand when you are truly suffering. It has never happened before.

My first job here is to build community leadership that will unite men and women to work with us to assess and meet the most important needs. But I called Monique, who is part of our leadership in Boston, this morning because the medical situation is really urgent and I think we need to attend to that crisis immediately. There is a clinic we could get people to but not now, in the rainy season. It’s impossible, the lake is too high and rough for the dugout. The cause of the illness is probably the water, but we know that’s going to have to wait until the dry season to be worked on.

We are going to try to get the clinic to visit our village with medicine. Thanks to you, our donors, we can actually pay for medicine, which the clinic can’t. When sick people go there, they don’t have medicine to give them except once. They give them a prescription but nobody has the money or access to fill it. And if our solution of having the doctor come to us won’t work we’re just going to find a motor boat!

We are going to save lives right away on this trip. A very joyful thing.Samuel KuaclietVolunteer Project Manager

Thursday, May 20, 2010

We received a pleasant surprise today when Mayor Tom Menino named our hospital Boston's Most Bike-Friendly Business. I think part of the reason was that we donate medical services for the annual Hub on Wheels charity bike ride. We were also an early contributor and advocate among other business to support Boston Bike Share, a forthcoming program to provide bikes on demand throughout the city to people.Whatever the reasons, thanks to Mayor Menino and his bike czarina, Nicole Freedman, for the recognition.

Wednesday, May 19, 2010

Dartmouth's President Jim Kim and his colleague James Weinstein make a sensible suggestion in an opinion article in the Washington Post, entitled, "Health Reform's Next Test."

We propose the rapid expansion of a new field to tackle the twin problems of how to provide high-quality health care while lowering costs: health-care delivery science.

...Experts in management, systems thinking and engineering, sociology, anthropology, environmental science, economics, medicine, health policy and other fields must join together to apply a laser focus to fixing the delivery system.

...We need a whole new cadre of people committed to applying their expertise to the challenge of health-care delivery.

We have begun building that cadre at Dartmouth with the establishment of a Center for Health Care Delivery Science. But it is our hope that many more institutions will work together to generate the needed evidence on health-care delivery solutions, to disseminate that knowledge and to train the current and future professionals who will put solutions into practice. We envision a network of centers across the country that will marry research and implementation from the start -- finding and testing delivery solutions with practitioners and patients on the front lines.

The four Massachusetts medical schools could be key partners in this effort, especially if they worked together to design coordinated curricula and research opportunities for faculty and students. I met with Jim Kim when he was at Harvard, before he knew he was going to be offered the Dartmouth job, and we talked excitedly about this possibility. That meeting is what prompted this blog post in July of 2008:

When will the thoughtful deans of our medical schools take on the concept of introducing the science of care delivery as a major focus of the curriculum, so that their faculty and new generations of doctors come to believe that field to be as interesting as the study of disease, diagnosis, and therapies? The opportunity exists for leadership opportunities for those universities that pave the way in this arena.

Lucien Leape has addressed this need in detail. Jim now generously offers the idea of a multi-institutional partnership. Is there a chance our folks will join in?

Tuesday, May 18, 2010

A well-established technique in negotiation is to "set an anchor." The idea is to be the first person to put out an offer in a negotiation in which price is the main issue. Many people think, incorrectly, that you are better off if you let the other party make the first offer. But, no. An anchor, once set, has a powerful impact on the negotiation, causing the final price to settle in its vicinity -- even if the anchor has no substantive basis.

I fear that we are seeing this phenomenon happening in Massachusetts. Many of you have followed our current controversy regarding insurance rates for individuals and small businesses. Lots of people with these kind of insurance policies found themselves with large premium increases this year.

The state legislature is engaged in dealing with this problem, and one idea pending is that the hospitals should contribute $100 million to help alleviate these premium increases. I am not gong to comment here on whether that source of funds is the right or wrong one. But I am going to comment on a dynamic surrounding the current negotiations.

Several weeks ago, the Partners Healthcare System volunteered to donate $40 million to this problem. On the one hand, this could appear generous. On the other hand, as noted by Boston Globe columnist Yvonne Abraham, it can be viewed as less than generous.

But the point is that PHS set an anchor with its offer, one that now leads some legislators to think that PHS has "done its share" and that the other hospitals should come up with the remaining $60 million. The usual dynamic that we could expect at this point is for the remaining hospitals to squabble among themselves as to who will pay what portion of this. That puts individual legislators in difficult positions, as many of the hospitals are the major employers in their districts.

The real point, though, is that the PHS anchor has no legitimacy. This collection of academic medical centers, community hospitals, and about 4000 physicians in the state has received excess insurance rates that produced billions of dollars in extra revenue over the last decade. The system has used those funds to recruit physicians, direct care to its network, and build new facilities throughout the region, further building its market influence and ability to demand higher reimbursement rates. Who is to say that a one-time offer of $40 million is anywhere near a fair contribution to this problem?

Another lesson of negotiation theory is that an illegitimate anchor needs to be dislodged. The Attorney General has prepared a report showing the disparity in reimbursements received by systems in the state. The Legislature might consider drawing on that research to decide if the Partners anchor has dropped in the wrong part of the sea floor.

Over three years ago, while posting our rate of central infections, I asked the following questions:

If I can post these rates for BIDMC, why can't people from other hospitals? ... Why can't the insurance companies? ... Why can't the state of Massachusetts? ... Real-time public disclosure of key indicators like this ... can be mutually instructive and can help provide an incentive to all of us to do better.

Well, Massachusetts is getting passed by on this front. Here is a presentation showing the rate of central line infections for all of the hospitals in Illinois for 2009. If you sort on the column "infections per 1,000 central line days" by clicking on that header, you will find 50 hospitals with zero infections, and 31 more with fewer than one per 1,000.

This kind of presentation does not require state action. The Massachusetts hospitals could together decide to do this voluntarily. We all collect the data for our own hospitals. It would impose no administrative burden to forward it for publication to a collective website. (Look here to see BIDMC's figure, posted every quarter.)

What more persuasive way to demonstrate to the public and to legislators that we collectively are serious about eliminating one important form of hospital acquired infection? That we are willing to be held individually and collectively accountable to a standard of care to reduce harm to patients? That we likewise are willing to be held to a standard of care that also saves dollars for an overburdened health care system?

Ten years ago, Dr. Bob Chase would have laughed if someone had told him common infections could be eliminated in hospitals' intensive care units.

"I would have said that's ridiculous, not possible," he said. "As a physician, I was trained to believe bad things just happen."

But Chase, vice president of quality at Norwegian American Hospital in Chicago, doesn't think that anymore. A growing body of research has convinced him that many infections can be prevented if proper procedures are rigorously followed — evidence he's using to reduce higher-than-expected infection rates at his own institution.

The research is prompting a wave of improvements in hospital ICUs, and patients are starting to benefit: At many hospitals, the rates of some common infections have been cut in half or more, saving lives and money and preventing medical complications.

Why are the health care leaders in Massachusetts so timid on this issue?

Monday, May 17, 2010

It was time for our annual National Nurses Week Celebration at Fenway Park tonight. We gave out awards and tens of thousands of dollars in scholarships, many provided by generous donations from people in the community. The person with the celebratory tiara above is Angela Kelly, who received the first-ever award for excellence in orthopaedic nursing care. The award is named for Dr. Harris Yett, a beloved orthopaedic surgeon. Angela is seen here with Dr. Pete Panzica, Clinical Director & Vice Chief in our Department of Anesthesia.

Wally, the Red Sox mascot, was there signing autographs and flashing his famous smile. And of course, the famous Fenway hot dogs were available, too!

My friends and colleagues Jeff Stamps and Jessica Lipnack have made an art and science of studying complex organizations. Their particular focus is on how communication within and across networks of relationships either enhances or degrades a company's ability to succeed. I recently looked at some draft work they have in progress, based on earlier work they have done. I think it is timely to share it with you (with their permission).

Jeff and Jessica raise provocative and timely questions for those of us implementing the Lean philosophy in complex hospital settings, or even for those who just are trying to manage in these kind of institutions.

In this long season of forced reorganization how are you facing complexity? Are you reducing or increasing your ability to make good decisions?

For the past thirty years or so, the prevailing wisdom about organizations is this: the flatter, the better. An inch-high and a mile wide. Smash the hierarchy. Nowhere was this more evident than in the corporate press release of the then-new CEO of BP. In October, 2007, Tony Hayward said his company was determined “to improve performance by simplifying how the company is structured and run.” While emphasizing that they have the right strategy and resources, he described BP’s problem this way: “…we are not consistent and our organization has grown too complex.”

Got your attention?

To remedy the situation, BP planed to adopt more standardized procedures and reduce the number of management layers from 11 to seven.”D What major benefit did Hayward expect to gain from redesigning the organization? “… [T]he revenue boost expected from greatly improved operational efficiency over the longer term.”

No one would argue that simplification is indeed more efficient, but here’s the rub: It’s not necessarily more effective.

Back in January, 2008, Jeff and Jessica privately predicted that Hayward’s BP reorganization would be suicidal. Now they say:

In light of the deep water explosion and gusher into the gulf that erupted on April 20, 2010, BP’s management structure is of vital, urgent interest as part of understanding what happened. Ominously, executives from BP promised Senators they would “fix” the management problems. If they do more of the same “reorganization,” they will compound an already disastrous situation.

Dogmatic global mandates, like one that says an organization must have no more than seven levels or that all managers should have ten reports (which a global financial management firm facing layoffs just executed), ignore other realities of business life. The number of levels your organization needs, or the optimal reporting span of your leaders, our research shows, is likely a function of what those units are actually doing.

Extensive study of one organization’s structure shows that some parts of organizations are shallow, others deep—depending on what they’re doing. Groups whose primary need is to communicate call for shallow structures that allow them to quickly spread messages; units engaged in complex decision-making require deeper structures that accommodate more specialization. The best structure fits the work at hand.

Saturday, May 15, 2010

Many of you may have wondered why I have not been more outspoken to date about issues surrounding my recently disclosed leadership errors. The reason was that my Board of Directors at BIDMC was still considering the issues. Therefore, it wasn't yet timely for me to address them beyond authorized formal statements, what you have seen here and in the media. On Thursday night, the chair of our Board suggested to me that it would now be appropriate for me to meet with the media and discuss the case.

I did so yesterday in the first of several interviews, which will likely continue into next week. Here are Liz Kowalczyk's story in the Boston Globe; another by Jerry Kronenberg in the Boston Herald; and a third, an interview with Jon Keller on WBZ-TV.

Thursday, May 13, 2010

We have an old pharmacy on one side of our campus, and it is time to rehabilitate it. We decided to use Lean principles in designing the new space. To do this, we pulled together a team of people, virtually anyone who touches the pharmacy or its products to look at work flows, find waste, and design a future state.Part of that analysis is a "process failure mode effects analysis," which is basically a risk mitigation technique. Especially for a critical area like the pharmacy, you want to anticipate in advance where failures in process are likely to occur, so you can design the work flow to minimize those.

But this assignment also required a view of how the actual physical facility would work. So we used an empty floor of a neighboring building and built a full-scale mock-up using cardboard boxes and the like. Then people simulated the new work flow to keep refining the plan.

Here's a video showing some scenes from this exercise. If you can't see the video, click here.

Wednesday, May 12, 2010

Jim Stergios and Amy Lischko from the Pioneer Institute write a well reasoned op-ed article in today's Boston Globe about current events in Massachusetts, where the Insurance Commissioner has decided to impose arbitrary price controls on a portion of the health care insurance market. More background here.

The consequences of this action are starting to be felt. Blue Cross Blue Shield of Massachusetts sent out a letter this week to the state's hospitals in which it notes:

In the coming weeks, we will work directly with individual hospital and physician groups on ways to reduce the payments we make to physicians and hospitals in the near term.

My translation of this is that those hospitals whose contracts come up for renewal this year will get no increase in their reimbursement rates from BCBS. Presumably other insurers will do likewise. These actions are predictable in that these insurance companies, under the supervision of the same Commissioner of Insurance, are required to maintain certain capital reserve levels. If they can't charge customers the actuarially appropriate rates for insurance, their only option is to charge other customers higher rates or to stiff the hospitals and doctors.

Ironically, though, the approach now being taken will aggravate an underlying problem in the Massachusetts insurance market, a problem documented in full by the Attorney General just a few weeks ago: The large disparity in rates paid to hospitals and physician groups based on their market power. The large, powerful groups who have contracts extending beyond the current period will continue to get their disproportionate rates -- and, indeed, annual rate increases based on a percentage of those rates. The "have-nots" who happen to be up for renewal this year will find their rates frozen, and the differential with the "haves" will grow.

The further irony of this approach, too, is that the current crisis in small business insurance rates is fundamentally not a hospital and physician cost issue. Hospitals and doctors do not charge different amounts to serve subscribers from small businesses and individuals than those from large businesses. It is the manner in which ratings are done by the insurance companies that drives the differentials in premiums. Those rating decisions are based on actuarial factors. One of those factors is that small business and individual subscribers do not have a single open enrollment period: They can enter and leave the insurance marketplace based on subscribers' health. They are the ultimate example of adverse selection.

Eventually, the courts may rule on the legality of the Commissioner's actions, but damage will be done in the meantime. Several of those "have-not" hospitals are the major employers in their communities. Their main options for dealing with reimbursement deficiencies will be to cut back on staffing, capital investment in needed clinical areas, and service to their cities and towns. Damage will be done to the "economic growth engine" of the Massachusetts economy, the health care sector. Also, public confidence in the state's ability to implement its landmark health care reform approach will be reduced.

Tuesday, May 11, 2010

At a recent presentation, a respected doctor expressed some frustration with the criticism that is sometimes directed towards the medical profession. He pointed out that the medical community has actually done a very good job taking care of serious illnesses in the population. He noted that this is because doctors really devote their lives to improving patient outcomes.

To support this point, he presented the chart above from the AHRQ Center for Delivery, Organizations and Markets (full study here) that demonstrates improvement in hospital risk-adjusted mortality for important diagnoses and procedures. Whether you have a heart attack or pneumonia, or whether you have an aneurysm repair or a hip replacement, your chance of dying in a hospital has gone down over the years. (I know this data ends in 2004, but I would be confident that the trends have held.)

I hope you, like I, am impressed with these numbers. They are a story worth telling and retelling.

But there is another story that has to be retold, too. It remains a bit of a paradox for me, one I discuss in my speeches. The paradox is how this group of extremely able and well intentioned clinicians, while accomplishing these great things, also constitute an important public health hazard, in terms of the number of people who are killed or otherwise harmed while in hospitals.

The famous Institute of Medicine Report, To Err is Human, was published in 2000. It documented, in a way that many people find uncomfortable, the number of unnecessary deaths that occur in hospitals. We now understand that much of this harm is caused by the systems of care, by how work is organized in hospitals, by excessive levels of variation, or, to put it another way, by insufficient levels of standardization based on process improvement principles. I summarized Brent James on this point in a post below:

We continue to rely on the "craft of medicine", in which each physician practices as an independent expert -- in the face of huge clinical uncertainty (lack of clinical knowledge; rapidly increasing amount of medical knowledge; continued reliance on subjective judgment; and limitations of the expert mind when making complex decisions.)

And, as noted below, we also often do not draw on our greatest resource, patients, in the design of care delivery. And finally, many hospitals and doctors are held back by a fear or reluctance to publish clinical outcomes in real time so that organizations can hold themselves accountable.

Is the glass half full, or half empty? As in such cases, probably both. Let's give tremendous credit to the medical profession for what it has accomplished. But let's hope that members of the profession also take to heart the fact that the job of reducing harm is not nearly done.

Monday, May 10, 2010

This is not about anybody famous. In part, it is a personal remembrance, but it is also a story of a fulfilled American dream. A college roommate and close friend of mine, Bob Lee, died a few days ago after a lengthy illness. I thought some of you would enjoy a section of his obituary, into which I have inserted a personal story, too:

Robert A.S. Lee, a mulitalented mechanical engineer, musician, singer, and connoisseur, died Friday at age 62 after a lengthy illness.

He was born March 26, 1948, as Bobby Chin, and his parents, first-generation Chinese immigrants, settled in Cambridge. All of his relatives came into the US by way of San Francisco in the late 1940s, but his mother, Mary Lee, decided that all of her children would go to MIT and continued on with her husband, Henry, to Cambridge. There, they opened the Silver Eagle Laundry, next door to their good friends, the Berkowitzes, who had just opened the Legal Fish market - the precursor to Legal Seafood - in Inman Square. Bob grew up ironing and folding shirts at the Silver Eagle alongside his father. There he played stickball in the alley while he was babysitting his youger brother, Ed, and his sister, Lana.

Since he was the first-born in an Asian family, Bob always had steak for breakfast while Ed and Lana were only given scrambled eggs.

After attending Longfellow School, he went on to graduate from Cambridge High School. In accordance with his mother’s plan, Bob attended MIT, obtaining both his graduate and undergraduate degrees in mechanical engineering. It was there that his love of music was encouraged by John Oliver, who conducted the chorus at MIT.

Here's where I insert the story from me:

Bob had a habit of "conducting" with one hand while he was singing, reflecting the rhythm of the part he was singing. One day, John Oliver stopped the entire chorus and turned to him and said, "It's triplets, not dotted eighth notes." Bob said, "How did you know I was doing it wrong?" John said, "Because you were conducting in dotted eighths!"

Also during that time Bob felt a passionate objection to the Vietnam war. He participated in many local protests and also attended the Moratorium to End the War in Vietnam on October 15, 1969. Millions of Americans took the day off from work and school to participate in local demonstrations against the war.

After graduation from MIT, he was hired by the engineering firm of Stone & Webster in Boston. Because of his command of German from singing classical music, he was assigned to work at an engineering firm in Mannheim, Germany, for BBR. He and his wife, Marleen, had the oppportunity to travel all over Europe, but the overriding joy of being in Germany was his love of BMWs. He demanded that if he were to agree to the German assignment, Stone & Webster would have to supply him with a BMW. He spent much of his free time at the Hockenheim Ring on Sunday afternoons, and took driving lessons at the famed Nurnburg Ring.

After returning to the US, he and Marleen started a family of three daughters. He was extremely proud of his daughters' accomplishments in academics, dancing, and gymnastics, and their musical abililty on piano, violin, and oboe. He continued to sing when he wasn’t traveling with Handel & Hayden and the Stoneham Community Chorus. He also served for many years on the Stoneham Finance Board.

Around the same time, he went to work for Foster-Miller in Waltham (an MIT R&D think tank), where his ability to speak many languages was put to use marketing his robot CECIL. His retirement from Foster-Miller was celebrated with his favorite, cognac, being served.

Sunday, May 09, 2010

I have reported below on Dr. Epstein's remarks about the place of compassion in medical care. (I provided the video excerpt because seeing it said is inspirational.) Who can doubt the worth of doctors like the two Dr. Epstein's as they consciously practiced this form of care delivery with their patients? We are so fortunate to have people like them.

But compassion has to show up in the actual physical delivery of care as well. We need to be ever alert that the day-to-day actions we take in the hospital can inadvertently send a signal that we don't care. Even when we have the best of intentions.

Here is an example of a lapse. The bad news is that it occurred. The good news is that our staff immediately responded when it was pointed out.

Here was my initial email to a couple of senior level clinical and administrative leaders:

I'd like you please to look into this and apply a Lean approach to the problem. The instant case was my friend Mary [name changed], but she says she has experienced it before and has seen other chemotherapy patients go through the same problem.

She is a chemotherapy patient who comes in for periodic CAT scans. The chemotherapy affects the blood vessels and makes it difficult to insert an IV for the contrast agent. The techs are not trained to insert these difficult IVs. They try several times, causing pain and swelling of these cancer patients, and then finally the special IV team is called. When Mary has asked for the special IV team to be called at the outset, she is told that there is no way to coordinate those teams with the CAT scan outpatients.

That, to me, is an unacceptable answer. These patients come in on a known schedule. They have a known problem. We do not respect that problem sufficiently to avoid the discomfort and pain that comes from multiple attempts to place the needle.

I saw Mary's arm after her appointment. Much of the lower portion of her arm was discolored and swelled up and painful to her. That is no way to treat a patient with metastatic cancer. We have to do better. Please keep me up to date as you resolve the issue.

In just a few days, I received the following response.

An update on the venous access situation. The working group consisting of the individuals listed below has met. Amy G. is investigating the best way to create a flag in BIDMC systems for those patients who are "difficult sticks", with the accompanying ability to unflag (many patients change vein status as their health conditions change). Once the flag system is functional, clinicians will be trained on how to generate flags for these patients in the system. Amy is also investigating how to provide an electronic dashboard to the Venous Access nurses, so that they know every morning where and when flagged patients have appointments during the day so as to be available when needed. Currently there is a white board/paper/phone based system which doesn't enable proactivity.

As these capabilities come on line, Barbara C. will work on scheduling her team for on-time availability, Donna H.will train Radiology schedulers on the new process to follow when scheduling flagged patients, and training will be deployed to insure that the nurses know how and when to flag and de-flag appropriate patients. No doubt there will be additional actions required as these changes are implemented.

While these improvements are underway, heme onc and radiology will continue their current process for managing patients with difficult veins:1) When any patient requests the special IV team to insert an IV, the Venous Access Team is called. No one else attempts to insert the IV.2) Some "frequent flyer" patients are known by the nurses and techs to be difficult sticks and special assistance from the Radiology nurse or Venous Access Team is initiated. The tech will call for Radiology nurse or IV nurse assistance as needed. Right now they can't be flagged ahead of time, so there can be a wait for nurse assistance.2) For patients who do not make a special request, and for whom there is a reasonable expectation that insertion will be successful, the radiology tech will attempt to insert an IV once. If it is unsuccessful, the tech will determine whether an IV nurse is needed or whether a second attempt is likely to be successful (most insertions are successful by the second attempt). If the 2nd attempt is unsuccessful, the tech will call for either a Radiology nurse who has advanced skills in difficult sticks or for an IV nurse to insert the IV.

I think you will agree that these are good responses, and our folks deserve credit for their quick action. But, thanks to the training I have received from people like IHI's Maureen Bisognano and Jim Conway and e-Patient Dave, I then proposed one additional step:

One more thought on this, which is excellent work.

Why not convene a small focus group of such patients and go through the suggested new process with them to see if they like it or have other suggestions? Wouldn't that be consistent with our attempt to be more patient centered and engage patients in our decision-making?

You see, compassionate care does not occur solely because there are well-intentioned clinicians. It has to result from thoughtfully designed work flows that avoid harm to patients -- work flows that are not dependent on patients' self-advocacy when they are in vulnerable settings.

To do it right, though, compassionate care has to be designed with the help of the very patients we serve.

Try as we might, there is no way to for us to see things through their eyes. We have to welcome them to be there to help guide us.

A good friend (and, full disclosure, cousin*) of mine, Benjamin Kanters, recently told me about work he and others are doing to try to help musicians avoid hearing loss. I had not realized the extent of this problem, but it is a big deal, and the story has been around for a while. It is not just hard rock musicians. A quick web search, for example, turns up this paper:

A 1981 study at Sweden's Concert Hall and Lyric Theatre in Gothenberg revealed that 59 out of 139 orchestra musicians (42%) had hearing losses greater than that expected for their ages.

AFTER 40 years of being seated near the braying brass section in the Chicago Symphony Orchestra, first violinist Fred Spector was struck with a potentially career-ending occupational disability when he couldn't hear the violins on his left. The 71-year-old musician, who began playing at the age of 4, says over the telephone, "Believe it or not, I am having trouble hearing you."

Pete Townsend, the force behind The Who and 07 Tony award-winner for the Broadway adaptation of Townsend's rock opera, Tommy, has gone public about his hearing loss on several occasions. . . .Today, an older, wiser and deafer Townsend has worked to warn up-and-comers about the seriousness of sound-induced hearing loss. But its a tough sell to a demographic that believes its better to burn out than fade away.

My cousin has started an organization to spread the word and conducts workshops around the country on the topic. He was here in Boston recently presenting at a couple of the local music schools. Of course, he is not alone. The National Hearing Conservation Association comprises a diverse membership, all dedicated to the cause of promoting hearing health.

Meanwhile, too, there are equipment vendors who are making musicians' earplugs and in-ear monitors. I don't here endorse any, but here is one sample and here is another. By combining solid state circuitry with a custom-fitted ear plug, the sound distortion is reduced while providing protection to the delicate parts of the ear.

So whether you or your kids play in orchestras or rock groups, or are involved in recording them or managing their concerts, it is worthwhile to give some thought to protecting this sensitive part of the body.

---* I share no financial interests with this person. We don't even give each other birthday presents!

Saturday, May 08, 2010

It is time for the annual Studios Without Walls art exhibit along the Muddy River in Boston. (You read about this here last year, too.) Here are two samples of the works. This is a great location, frequented by thousands of commuters and other walkers every day. The show will be up until June 13.

Dr. Frank Epstein (seen above in 1979), a former Chief of Medicine here, was beloved and respected. When he died, the Department of Medicine created a lecture series in his honor. The first Grand Rounds speaker yesterday was Jonathan Epstein, Frank's son (seen here with his dad!) Jonathan is Chairman of the Department of Cell and Developmental Biology at the University of Pennsylvania, where he is also Scientific Director of the Penn Cardiovascular Institute.

Dr. Epstein's lecture will appear in article form in the near future, so I don't want to steal his thunder. The main topic was congestive heart failure and the potential for new work in genetics that might be used to treat it. Today, treatment is generally based on interventions that improve the hemodynamics of the body, not treatment that helps the heart itself.

But the heart and soul of Jonathan's talk was about the relationship his father had with his patients and how that pattern of care could set an example for doctors in general. Dr. Epstein was known for taking the time necessary to get to know his patients, their family background, and other personal information that could assist in diagnosis and treatment. He realized that the most sophisticated tests and therapies were but tools in the total treatment of the patient, and that the doctor-patient relationship was all important. When a patient arrived late for an appointment and apologized, Frank said, "Don't worry, I have all the time in the world."

Jonathan's description reminded me of the speech given by Dr. Amy Ship a few months ago, which I again recommend. But then he elaborated on it by quoting a portion of his father's last grand rounds. Here's a similar quote from an article, "The Role of the Physician in the Preservation of Life." Q J Med 2007; 100:585–589.

We physicians belong to an ancient profession, standing apart from all others in its primary concern and respect for human life and its enmity to death. And in the long run, that attitude of the profession may be as important to society as any miracle that modern technical medicine can perform.

The fact is that for all our talk and our science, we do only a little. Life cannot be prolongedindefinitely, and death comes at last. But the little we can do has an importance that transcends the patient, for it carries a message to all our patients and to the world: Human beings are important.

Thursday, May 06, 2010

A close friend of mine, in his 40's, had a persistent light cough for many months. Finally, when he had an X-ray taken, it showed a large tumor on his lungs. He was diagnosed with stage 4 lung cancer. As a non-smoker and strapping, physically fit man, he was shocked, as you can imagine.

He went to his non-Boston-based medical practice, and he was told the prognosis was 12 to 18 months before he would die. They offered him, though, the chance to enroll in a clinical trial, based on a cocktail of chemotherapy agents.

Meanwhile, he wrote to me and another hospital-based friend in Boston, and our cancer experts in both places pointed out that there is a particular genotype of tumor that is susceptible to an oral chemotherapy drug. This type of tumor is present, in the case of non-smokers, about 17% of the time. Folks here recommended that he have a biopsy to see if he was "lucky."

When he went back to his local medical practice and relayed this information from two of the world's greatest oncologists, the local doctor discouraged him from getting the biopsy. He said that recovery from the biopsy operation would delay the start of the clinical trial by a month. The doctor intimated that there were very few slots left in the trial and that my friend might be excluded if he waited.

My friend chose to ignore the local doctor's recommendation, relying on the advice of the Boston doctors. He came here and had the biopsy. It was a match. He started the chemotherapy regime, and it shrunk the tumor by 90%. This enabled it to be surgically removed, with good pathology results in the surrounding tissues. After surgery, he returned home in good shape and has started a maintenance chemotherapy program.

Upon returning home, too, he discovered that the local clinical trial actually was not at all fully subscribed, that they have been having trouble getting enough subjects.

The conclusions I draw from this are very distasteful. Perhaps I am too close to this because it involved a friend, and perhaps others of you see this differently; but I see a medical practice that intentionally put one its patients at risk to support the professional advancement of one of its doctors, and perhaps the financial advancement of that person or the practice, too.

It’s hard to imagine a discussion about improving health care without mentioning “lean thinking” or “doing more with less”; how about striving for “zero defects” or “eliminating Muda” or waste? The principles that fuel the Toyota Production System (TPS) are so embedded in the way we think about health care quality, it’s no wonder the car manufacturer’s recent safety problems have been troubling and cause for concern far beyond the world of auto makers alone.

But, as with everything else Toyota, this detour from its own core values and the U-turn now taking place to get back to them are providing new learning for health care. Who better to tease this out for us than Steve Spear, John Toussaint, and Gary Kaplan, three individuals whose careers have been profoundly shaped by adapting the best of TPS thinking to health care delivery.

Bring your ears and your wisdom to WIHI on May 6 -- and note that we’re starting a bit later in the afternoon so John Toussaint can join us from Australia. To enroll, please click here.

The American Hospital Association does excellent work in representing the views and interests of hospitals across America, and it genuinely seeks to help frame medical and hospital issues in a way that serves the public interest.

But because it is a membership-based organization, it can be hard to be as aggressive on some issues as the times call for. One such discussion is going on right now. The Association is considering a number of strategic performance commitments, one of which is to "advance a health care delivery system that improves health and health care."

I can't argue against that goal, but the manner in which it would be pursued and quantified is weak. See the slide above. It is the draft of what is being discussed by hospital associations across the country.

The first two items are certainly worthy, but the manner in which they are measured is problematic. The metric is a three-year running average produced by CMS and published a year after the year is over. Accordingly, no one will know if the 2012 target is met until 2014.

Why rely on administrative data collected by CMS when every hospital has its own data in real time? Why use a three-year rolling average when we are trying to demonstrate progress over the coming year or two?

The third goal, to achieve improvements in central line infection rates, is simply inadequate on its face. The idea of taking three years to move from the 2009 baseline of 5 cases per thousand patient days to a new target of 1 in 2012 does not reflect the deadliness of hospital acquired infections nor the progress that any hospital can make to reduce them in just in a few months.

The target for central line infections should be zero. That is the only intellectually compelling goal. The time period for doing this should be much, much shorter.

When I first read this article*, "Electronic medical orders may save lives," I thought it was a hold-over from five years ago. But, no, it is current. It suggests that this is the first time someone has been able to document that a computerized provider order entry (CPOE) system has saved lives in a pediatric setting.

I believe in evidence-based medicine and scientific studies, but this looks like a study with an overly limited outlook that may cause some people to question the value of CPOE. Sure it is great to save lives, but most medication errors don't kill people. Most of them result in increased morbidity, extended length of stay, or other things short of death.

In light of these facts, a quote like this in the article leaves me bewildered:

The debate over whether CPOE is working as intended is hardly over, said Menachemi: "I think it would be foolish to believe that any one study can end the discussion."

Let's go back to the basics. Hand-written drug orders are subject to transcription errors at both ends, the person writing them and the person reading them. Each time you add an intermediary in the drug ordering process, you add an opportunity for error. Also, unless there is real-time and accurate checking for drug-drug interactions, allergies, assessment of doses based on body weight and the like, there will be some percentage of preventable medication errors.

Maybe I live in a rarefied world of early CPOE adopters, but does anyone out there think this is still subject to debate? Instead, let's focus on enhancing the implementation process for CPOE, as well as maintaining the functionality of the systems that are installed. Check John Halamka's blog for commonly made mistakes on these fronts.

Monday, May 03, 2010

The Board of Directors of BIDMC today issued the following statement, which has been distributed to the media and to the entire hospital community.

The Board of Directors of Beth Israel Deaconess Medical Center, with the assistance of outside counsel, has completed its review of allegations made involving President and CEO Paul Levy. The review focused on a personal relationship with a former employee of the Medical Center. The Board found that over time the situation created an improper appearance and became a distraction within the hospital.

The Board believes that Mr. Levy should have recognized this situation in a more timely fashion and should have conducted himself in keeping with business protocol appropriate for the office of the CEO.

Mr. Levy agrees that it was a serious lapse in judgment and agrees with the Board’s conclusions. He has apologized to us and to the entire staff of the hospital.

Although our outside counsel found that Mr. Levy did not violate hospital policy, the board determined that he showed poor judgment and the board expressed its disappointment. Accordingly, the board has voted to take appropriate actions by:

1. imposing a financial penalty of $50,000 to be paid to the hospital in the current fiscal year.2. instructing that this matter be considered in determining the CEO's compensation for the next fiscal year.

Although in this instance, Mr. Levy has not lived up to the standards we set for our CEO, the Board also considered his exemplary record over the course of his tenure at BIDMC, the current performance of the hospital, his role as the chief architect of the hospital’s leading position in quality and safety, and his bold voice of leadership on public policy. Under Mr. Levy’s direction, the hospital has reclaimed its rightful place as one of the region’s preeminent providers of health care, medical education and research. The board again expressed its full support and confidence in his continued leadership, and considers this matter closed.

I have issued the following statement, which has likewise been distributed to the media and to the entire hospital community.

I appreciate the Board's thoughtful consideration of this issue. I agree with their conclusions that I made an error of judgment, and I believe the Board has acted appropriately.

Today I met with the Board, apologized to them again, and accepted their actions in resolving this matter. I regret that my behavior had such wide repercussions for the entire BIDMC community, and I will always feel sorry for any discredit I brought upon BIDMC. With the Board's vote, I look forward to putting this chapter behind us and working together in carrying out our public service mission.

I now here also issue these statements to my other community, the loyal readers of this blog, but I have one other comment.

For those of you who have come to rely on me for my pursuit of quality and safety of care and continuous process improvement in our hospitals, I hope that this series of events and revelations will not undercut the importance or validity of what I have been saying. I especially apologize to you if you feel that I have let you down and, in so doing, in any way weakened the case I have been making. We in the medical community have much to do in these areas. I hope we can together continue to engage in vigorous activity to help make health care safer and more patient-centered. I can't imagine more important goals for all of us to pursue.

Sunday, May 02, 2010

"Hats off to Dr. Susan Mackie, whose lucid, thoughtful, powerful essay "The Value of DNKs" is published in this week's New England Journal of Medicine.

"We are lucky to have her and her voice!"

Some excerpts:

DNK (pronounced"dink" and always uttered wistfully by the residents in my program)is the abbreviation that appears on our online schedule whena patient "did not keep" an appointment. DNKs obviously representsuboptimal care for the DNKing patients, as well as a financialloss for the practice. But as residents, we have all been guiltyof hoping for DNKs in our schedule. I had always thought ofthis desire as a sign of laziness, but on that day, I beganto suspect that the reason I felt I was a good doctor was largelythe result of my two DNKs. DNKs create time. Time allows usto build relationships. And what is primary care about if notrelationships?

. . . As I progress in my career, pressures to improve the qualityof the care I provide will inevitably grow, as will my patients'expectations. Less certain is what will happen to the amountof time I can devote to the care of each patient. Enthusiastically,and perhaps naively, I have mentioned to my mentors that I lookforward to a future in which I will be able to share responsibilitieswith nurse practitioners and physician's assistants in sucha way that my appointments with patients will be fewer, morethorough, and more satisfying for everyone involved. None ofthe experienced physicians I've talked to have confidently embracedthis vision. Perhaps they have seen too many changes for theworse to believe that a change for the better is possible.

. . . I firmly believe that adequate time — not simply perceivedtime, but real time — is an indispensable component ofour encounters with patients if we are to be good doctors. Howsufficient time can be most effectively incorporated into thestructure of primary care delivery, given its payment constraintsand expectations of quality, should be the subject of ongoingresearch, as new policies are codified. In the meantime, I willcontinue to take guilty pleasure from DNKs.

A friend highly recommends this book by some folks at Dartmouth Medical School, entitled Know Your Chances. The idea is to provide a simple description of how you can evaluate publicly propagated information about diseases and therapies. Here's more. An excerpt:

From drug companies to disease advocacy groups, everyone "is trying to grab your attention by making their disease sound as common or as dangerous as they can," says Dr. Lisa Schwartz. But in the process, lots of messages get exaggerated. It can be tough for patients to cut through the hype and determine what—if any—accurate information remains.

So Schwartz and two other members of the DMS faculty—Drs. Steven Woloshin and Gilbert Welch—wrote a book to help people assess messages about health statistics.